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0 0 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SITE HEALTH AND SAFETY PLAN <br /> PART I PARTI11 <br /> GENERAL SITE INFORMATION EVALUATION OF POTENTIAL HAZARDS <br /> 1. Site Name: P�OSO <br /> Address: TO 7-0 GM^� t-t"IE R-V 1. Chemicals Hazards <br /> x'36-250( E3 Carcinogens: <br /> Contact Person: Phone No: ❑Corrosives: <br /> Sweeps Number: ❑Dusts: <br /> Proposed Date of investigation/inspection: ❑Explosives: <br /> WFlammables: <br /> 2. Description and brief narrative of inspection activity: ❑Inorganic Gases: <br /> ❑New UST installation.. ❑UAR Investigation. ❑Metals: <br /> ❑Tank Closure in Place.. ❑Tank/Pipe Repair. ❑Oxidizers: <br /> ❑Tank/Pipe Removal. ❑Re-excavation. <br /> ❑PCB's: <br /> k❑Installation of Borings/Monitoring Wells. <br /> yy Hazardous waste inspection ❑ Sampling <br /> [ � PART III <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank No.: Tank Capacity: 1. Monitoring Equipment(note:Monitoring instruments must be used for all <br /> Tank Content: Tank Age: operations unless appropriate rationale or restrictions are provided) <br /> Other: ❑Combustible Gas/Oxygen Meter. <br /> I ❑Detector Tubes(Specify). <br /> 4. Type of Operation:_ V <br /> f�/�/py✓�/ ❑Photo ionization Detector. <br /> ❑Organic Vapor Analyzer. <br /> 5. Release History: <br /> ❑Other,specify. <br /> Evidence of leaks/soil contamination: <br /> ❑YES ❑NO If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Documented Groundwater contamination: ❑YES ❑NO <br /> Background and description of any previous investigation or incidence: <br /> 2. Personal Protective Equipment <br /> Level of Protection: ❑A ❑B ❑C 7fJ D <br /> 6. Potential Health and Safety Hard Hat. <br /> Physical Concerns:(check all that apply&describe) Safety Glasses/goggles. <br /> ❑Heat or Cold Stress: °F(high ambient temp.) Steel toed/shank shoes or boots. <br /> ❑Noise Sources: ❑Flame retardant coveralls. <br /> El Oxygen Deficiency: E]Hearing protection. <br /> ❑Excavation:(falls,trips,slipping,cave-ins): [I <br /> El <br /> Respirator: [I APR ❑SCBA <br /> Handling and Transfer of a Hazardous Substance:(fire,explosions, <br /> etc..): A/P cartridge: <br /> ❑Confined space entry:(explosions): ❑Safety vest. <br /> .)<Heavy equipment(physical injury&trauma resulting from moving ❑Two-way communication. <br /> ( 'equipment): <br /> ❑Other,specify PART IV-PLAN APPROVAL <br /> 7. Anticipated Biological Hazards: I, �(� <br /> Plan Prepared by: V`� Date: <br /> ❑Snakes ❑bisects ❑Rodents ❑Poisonous Plants <br /> ❑Other/Unknown(specify): Plan Approved by:- V_2sj,0 Date: <br /> 8. Narrative(provide all information which could impact Health and Safety, I <br /> e.g.,power lines,integrity of dikes,terrain,etc.) <br /> EH 23081(02/19/03) <br />